Overview. Total Joint Replacement in the U.S. KP National Total Joint Registry EMR Tools and Outcome Assessment: A Model for Vascular Surgery?

Transcription

1 KP National Total Joint Registry EMR Tools and Outcome Assessment: A Model for Vascular Surgery? Liz Paxton Director of Surgical Outcomes and Analysis Overview KP Total Joint Replacement Registry Background Data collection and Quality control KPHC Smartforms KPHC Clarity queries Validation and quality control Benefits: Quality, Safety, Cost-effectiveness, Research Key learnings Expansion Application of registry model to a Stent registry Purpose/goals Benefits Data elements Next Steps 2 Total Joint Replacement in the U.S. Total Joint Replacement (TJR) in the U.S. 700,000 total knees (TKA) and hip (THA) 17,000 Kaiser Permanente Projected Volume 2030 (Kurtz et al., 2007; Khatod et al., 2008) Primary TKA 673% increase, Revision 601% Primary THA 174% increase, Revision 137% Projected Annual Hospital Charges 2015 (Kurtz et al., 2007) Primary THA $17.4 billion, TKA $40.8 billion Revision THA $3.8 billion, TKA $4.1 billion 3 1

2 Total Joint Replacement in the U.S. Lacked a national mechanism to Identify TJR revision rates Identify patients at risk for failures/ revisions Assess post-market implant performance Immediately identify and notify patients w/ recalled implants 4 Total Joint Replacement Registry Initiated in 2001 Modeled after Swedish Hip Registry Standardized documentation Pre-op Operative Follow-up TJR database Demographics Surgical techniques Implant characteristics Outcomes 5 SmartForms: MA Pre-Op 6 2

3 SmartForms: Knee Pre-Op 7 SmartForms: Hip Status 8 SmartForms: Progress Note 9 3

4 TJRR Quality Control & Validation Quality control queries w/chart review Out of range Inconsistent values Missing values Validation of procedure, diagnostic codes, implants Independent administrative databases Physician/OR logs Electronic screening algorithms w/chart review validation of complications Infections, DVT, PE and revisions CDC/AHRQ guidelines 10 Electronic Screening Algorithms 11 Total Joint Replacement Registry Data Sources Data Acquisition & Quality Data Aggregation & Storage SAS Analytics Information Delivery Pre-op form Data mapping, quality and transport Data Extraction Annual report Operative form Post-Op form Data entry shell Data cleaning & quality checks Total Joint Registry SQL Database Data Mining Data queries Ad hoc requests Personalized profiles Hospital Claims Membership Mortality Business Rules Data extract, transfer and load Data cleaning & quality checks Domains Patient demographics Implant characteristics Surgical techniques Outcomes Multivariate logistic regression Predictive Modeling Survival Analysis Web-based reports Risk calculator Research projects Recalls / advisories 12 4

5 Total Joint Replacement Registry Largest Registry in U.S. > 130,000 cases 350 orthopedic surgeons 95% voluntary participation 50 hospitals in 6 regions Hawaii Mid-Atlantic States Colorado Northern CA Northwest Southern CA 13 TJRR finding: Partial Knees (UKA) Lower Implant Survival 14 Changes in TKA Practice: Reduction in UKAs 5 4 % UKAs

6 TJRR Finding: Smaller head size lower survival 16 Changes in THA Practice: Reduction in Smaller Head Size Use 60 % 28 mm head size Identification of Patient Risk Factors 18 6

7 Implant Recalls & Advisories Timely, efficient patient identification & monitoring In 2009, 15 recalls, advisories, & implant concerns 2500 patients affected in our system alone 2010 ASR hip recall over 600 patients affected Early identification and prevention of defective device utilization Effectiveness New Tech Gender Specific Knee $1,000 extra Registry data indicated men and women similar ROM, satisfaction, pain, and revision rates Why needed? 21 7

8 Research Total Joint Replacement in the U.S. 50 national presentations/ publications AAOS 2011 Reverse Total Shoulder Arthroplasty Hemi and Total Shoulder Replacement risk of revision Total Joint Scientific exhibit Pre-coat TKAs implants THA gender differences in risk of revision Predictors of TKA revisions Success rates of ACLR w/meniscal repair Knee scope infections 22 Collaborations FDA: Evaluation of total hip & knee implants ICOR: International Consortium of Orthopedic Registries DELTA: Automated post-market surveillance Norwegian/Swedish registries CESR: KP Center for Effectiveness and Safety Research 23 Keys to Success MD involvement at all stages Direct feedback to clinical staff and MDs Minimal burden to frontline staff Leverage existing databases Rigorous quality control mechanisms and validation of outcomes 24 8

9 Registry Expansion Orthopedics 11,000 ACLR 2,500 Spine 3,000 Shoulder 20,000 Hip Fracture Cardiac STENTS? 16,000 ICDs 36,000 Pacemakers 76,000 Leads 17,000 Heart valves 25 Next Area for Expansion: EVAR Is the total joint model applicable to EVAR? Purpose/goals of an EVAR registry? Patient tracking/monitoring Outcome evaluation Comparative effectiveness Risk assessment Others? What important clinical questions could an EVAR registry help to answer? 26 EVAR Stent Registry Patient Data MRN Name Region Gender DOB Home Facility Hypertension (HTN) Coronary Artery Disease (CAD) History of Smoking Diabetes Hyperlipidemia BMI Peripheral Vascular Disease (PVD) Renal Failure / Dialysis 27 9

10 EVAR Stent Registry Pre-op Imagining/AAA Measurements CT Date Angiogram Date Ultrasound Date Imaging Study providing measurements Aortic Aneurism Aortic Uniiliac Aortic Biiliac Iliac only Infrarenal neck diameter Infrarenal neck length Distal Neck Diameter 28 EVAR Stent Registry Lab/Implant Data Pre-Op Creatinine Pre-Op Hemoglobin Post-Op Creatinine Post-Op Hemoglobin Manufacturer Catalog / Product number Implant Type (limb, cuff, etc) Size Location 29 EVAR Stent Registry Surgical Data Surgery Date Admit/Discharge Dates Surgery Loc (Fac) Implanting /Assisting Surgeon Assisting Radiologist Type of Anesthesia CFA Patch Endoleak at end of procedure (classification) Approach Estimated Blood Loss 30 10

11 EVAR Stent Registry Outcomes Device Migration Graft Tear Component Separation Device Fracture (Stent vs. Barb) Limb Occlusion Limb Kinking Post-procedure Rupture (Late vs. Early) Infection Endovascular Leak (Type 1 vs. Type 2) Stenosis Significant Blood Loss Thrombosis Failed Perclose Hematoma Surgical Conversion Secondary Intervention (Due to AAA enlargement vs. other) Renal Impairment Death Related to aneurysm 31 Next Steps Benchmark with existing registries Determine existing data elements available in KPHC Identify champions from each region Finalize registry data elements Identify potential data collection methods Behind the scenes KPHC Clarity data Chart review Smartforms Manufacturer registries Stand-alone vendor applications Implement! 32 Thank You Intranet site: The Permanente Journal registry web site: